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Introduction
Quality improvement organizations are not-for-profit organizations whose members are: qualified physicians, technicians, nurses, statisticians, and other professionals in the field of health care. Every state in the USA has a quality improvement organization that is contracted for a maximum of three years to help in the improvement of the standards of the health care provided to people. They are contracted by the Centers for Medicare and Medicaid services and they advise the Medicare trust on which health care products to pay for. They are usually quasi-governmental organization. This means that they are treated by state laws and regulations though they are separate and autonomous. They are funded by the government through centers for Medicare services. The core function of quality health care organizations is to ensure that Medicare beneficiaries receive quality and efficient health care. This paper will describe the quality improvement organizations, their functions, and the stakeholders affected by the organizations.. (Michael, 2006)
Functions of quality improvement organizations
The functions of the quality improvement organizations are summarized underutilization functions and review functions. Quality improvement organizations are supposed to review the services offered by health care professionals, doctors, providers of health care facilities, and suppliers of health care products. In its review, the QIO must determine the following.. (Michael, 2006)
Whether the services provided were the appropriate ones for the diagnosis and the treatment of the sickness for which the patient sought the services. They should determine whether the patient was given the right care in case of a terminal illness and whether the right vaccination was given in case of prevention of illness. They determine whether the health care provided by the health care providers meet the standards of health care stipulated in the codes.. (Kambic, 2006).
They review the economic aspect of the care. For example, they have to review whether outpatient care was more economical than inpatient care given to a patient. For a patient to be admitted, he or she must have an illness that can be treated only in an acute care facility. This implies that the patient should only be admitted if he is in a critical condition. If this is not done, the QIO involved will know after review and advice the CMS accordingly. Another important review is on whether the information about the illness, the diagnosis, and all other information given by the hospital is convincing. This review will determine cases where the physicians did the wrong diagnosis.. (Kambic, 2006).
The QIO review whether it was necessary to admit a patient in the hospital, whether it was necessary to discharge the patient at the time he or she was discharged, and whether the action taken (of admitting or discharging) led to problems incurred by the patient afterwords. In cases of surgery and surgical procedures, the QIO review the procedures to ascertain that they were excellent and orderly. (Kambic, 2006).
The QIO has the responsibility of determining whether all the services offered should be paid for. This will ensure that only reasonable and valid services are paid for. For example, some inpatient care departments will give two or three days for monitoring the patient and arranging the discharge procedures. It is the work of the QIO to note such a case because those extra days are not supposed to be paid for under the Medicare program. (Essay, 2005).
The QIO is supposed to submit information about diagnosis, discharge procedures, and the number of admissions to the Medicare physical intermediary every quarter. This will ensure that the information provided by the hospital is correct in case there arise any doubts on the integrity of the hospital. The QIO is also mandated with the responsibilities of coordinating sanction activities imposed on the providers and practitioners who abuse their obligations given unto them. They notify the health care facilities when they are likely to visit them for review of the above aspects. These are written notifications which among other things will specify the date and the information required. The notifications can be done either through newspapers or written memorandums. (Institute of Medicine. 2006.)
They also inform the consumers of their Medicare rights and responsibilities and sometimes represent the consumers in any dispute between the beneficiary and the service providers. They provide information about health care services, their availability, their standards, and also help the consumers in decision making about the health facility to choose. ( Peck, 2006).
It is evident that much of the functions of the QIO are review functions. This review however must be done under some general requirements. The review is supposed to be in agreement with the schedules, functions, and the objectives that were stipulated in the contract. They must notify the Medicare intermediary that they will review a certain health facility and this should be done five days before the review is done. (Essay, 2005).
Stakeholders affected by QIO
Since quality improvement organizations are concerned with ensuring the provision of appropriate and excellent health care, all other organizations involved with health care provision work hand in hand with QIO. These include:
Centers for Medicare and Medicaid services-the CMS is responsible for contracting the quality improvement organizations and this means that they will be answerable to it. In fact, the QIOs are funded by the government through the CMS.
The Medicare trust fund- these are responsible for paying for the services and goods offered by the service providers. The QIO ensures that Medicare pays only for services that have been provided in the best interest of the beneficiary. (QIO-LIKE ENTITY, 2006).
Health care providers-these are facilities that provide health care to patients. Nursing homes, home health agencies, doctors’ offices and hospitals are some of the common health care providers. They work hand in hand with the QIO. They are advised on how to improve clinical quality and safety by the QIO so that they can meet the standards required by the centers for Medicare services. (QIO-LIKE ENTITY, 2006).
The beneficiary-the beneficiary is the patient in most cases and the QIO have a responsibility of addressing complaints on behalf of the beneficiary. Complaints may sometimes occur if care was not provided in the correct manner. (QIO-LIKE ENTITY, 2006).
The congress-though not directly involved, must receive a published report about the QIO program. The report outlines issues of administration, the cost of maintaining the QIO program and how the QIO program is impacting in society. (Michael, 2006)
Conclusion
For the provision of good health care services, the health care providers have to be monitored; the beneficiaries have to be advised on their rights and on the right choices and all stakeholders of health care must coordinate to provide effective and quality services. It is the duty of quality improvement organizations to ensure that this happens. Research has shown that improvement in hospital care is as a result of among other things active involvement of the quality improvement organizations in health care.
Reference list
Essay, M. (2005). The QIO program, home health, and the national acute Care hospitalization priority. Home health care management program practice, 34-38.
Institute of Medicine. (2006). Medicare’s Quality Improvement Organization Program: Maximizing Potential. Washington, DC: National Academy of Sciences. Kambic RT, et al. (2006). Assessment of the Medicare Quality Improvement Organization Program. Ann Intern Med. 145:342-53.
Michael, O.L. (2006). Report to Congress on the Evaluation of the Quality Improvement Organization (QIO) Program for Medicare Beneficiaries for Fiscal Year 2006. Web.
Peck, W.A (2006). Enhancing the potential of quality improvement Organizations to improve quality of care. Ann intern med. 388-389.
QIO-LIKE ENTITY. (2006). Quality Improvement Organizations (QIOs). Web.
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